Provider Demographics
NPI:1740573542
Name:GREEN, CASEY LYNN (OTR/L)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:LYNN
Last Name:GREEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10612 WAYCROSS AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-5320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6025 PINE AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90270-3108
Practice Address - Country:US
Practice Address - Phone:323-560-0720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11688225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11688OtherCALIFORNIA BOARD OF OCCUPATIONAL THERAPY